The
Clinical Nurse/Clinician serves as a compassionate advocate for GuideStone members, leveraging clinical expertise and data-driven strategies to improve health outcomes and ensure cost stewardship. Key priorities include Member Outreach and Compassion Calls, Cost Containment and Savings, Clinical Data Analytics and Member Trends, and Multidisciplinary Collaboration. This role manages a defined member cohort, develops personalized care plans, and partners with internal teams and vendors to optimize clinical and financial outcomes.
What You'll Need:- Engage members through case management calls, develop care plans, address barriers, and encourage behavior change.
- Identify savings opportunities through process improvements, claims reviews, site-of-care optimization, and disease management programs.
- Use analytics to identify high-risk members and emerging trends; track and report outcomes for continuous improvement.
- Coordinate care during multidisciplinary rounds and collaborate with vendors to enhance member experience and outcomes.
- Demonstrate commitment to continuous professional growth and mastery of the job.
- Conduct prospective, concurrent, and retrospective reviews for medical necessity and level of care.
- Support audits, quality assurance, and compliance processes.
- Collaborate with Claims Team for member advocacy, benefit exceptions, and serve as a clinical resource.
What You'll Need:- Bachelor's degree in nursing required.
- 5-8 years in clinical practice, case management, disease management, provider operations, or health insurance.
- RN Compact License (or obtain within 6 months), BLS (AHA), and RN nurse liability insurance required.
- Oncology experience preferred, along with a broad clinical background (Medical-Surgical, Telemetry, PCU).
- National specialty certification and/or Case Management certification preferred.
- Proficient in MS Office and data analytics tools.
- Strong clinical judgment, data interpretation, and cost-awareness.
- Excellent communication, collaboration, and organizational skills.
- Ability to manage multiple priorities in a fast-paced environment.
- Cultural competency and experience with diverse populations.
- Proficient skills in MS Office and appropriate GuideStone system applications.
- Must have complete confidentiality regarding GuideStone business matters.
- Experience with payment integrity and coding is a plus.
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